Académique Documents
Professionnel Documents
Culture Documents
THROMBOSIS
Jane Chun-wen Teng D.O.
11/14/12
Virchows Triad
VIRCHOW'S TRIAD A major theory delineating the
Epidemiology
Among 1102 acutely ill, immobilized general medical
patients enrolled in the MEDENOX study, multiple logistic
regression analysis found the following factors to be
significantly and independently associated with an
increased risk for VTE, most of which were asymptomatic
and diagnosed by venography of both lower extremities
Presence of an acute infectious disease
Age >75 years
Cancer
History of prior VTE
rest
Recent surgery
Obesity
Prior episode(s) of venous thromboembolism
Lower extremity trauma
Malignancy
Use of oral contraceptives or hormone replacement
therapy
Pregnancy or postpartum status
Stroke
History of DVT
History Classic symptoms of DVT include swelling,
History of DVT
The patient should be carefully questioned concerning recent
History of DVT
Questions should include the presence of significant disorders,
Physical Exam
Physical examination may reveal a palpable cord
Livedo Reticularis
Physical Exam
There may be pain and tenderness in the thigh along the
Physical Exam
Only a difference in calf diameters (likelihood ratio, LR 1.8;
Physical Exam
Venous thromboembolism may also be associated with
Physical Exam
Phlegmasia cerulea dolens Phlegmasia cerulea
Physical Exam
Screening for malignancy Since venous
Laboratory Testing
The initial laboratory evaluation in patients with venous
Differential Diagnosis
When approaching the patient with suspected DVT of the lower
Diagnosis of DVT
A number of invasive and non-invasive approaches are possible (eg,
Diagnosis of DVT
A positive noninvasive study in patients with a first episode of
Diagnosis of DVT
Pretest probability Ultrasonography and D-dimer
tests for DVT are most useful when the results are
combined with an assessment of pretest probability of
DVT. One report of 593 patients with suspected DVT
validated a measure of pretest probability (Wells score)
VT was documented in 3, 17, and 75 percent of patients
Well Score
A review of 15 studies in which the Wells score was tested concluded
the following
Patients in the low pretest probability category had a median negative
be inherited or acquired:
Congenital/inherited (eg, factor V Leiden, protein C
deficiency)
Acquired (eg, following orthopedic surgery,
antiphospholipid antibody)
Associated with systemic disease (eg, malignancy)
Who to test There is currently no consensus regarding
who to test for inherited thrombophilia.
Value of Screening
Value of screening Although we can identify patients at increased
Value of Screening
Screening information can be used to identify family
Treatment of DVT
When unfractionated heparin is used, the dose should be
Treatment of DVT
For most patients, warfarin should be initiated
Treatment of DVT
The heparin product should be stopped if any one of the
Treatment of DVT
Oral anticoagulation with warfarin should prolong INR to a
Duration of treatment
Duration of treatment The duration of anticoagulation
Duration of Treatment
Indefinite therapy is preferred in patients with a first
Reference
http://www.uptodate.com/contents/overview-of-the-causes-of-venous-
thrombosis?source=search_result&search=deep+vein+thrombosis&selectedTitle=
6%7E150
http://www.uptodate.com/contents/deep-vein-thrombosis-and-pulmonaryembolism-in-pregnancy-epidemiology-pathogenesis-anddiagnosis?source=search_result&search=deep+vein+thrombosis&selectedTitle=5
%7E150
http://www.uptodate.com/contents/diagnosis-of-suspected-deep-vein-thrombosisof-the-lowerextremity?source=search_result&search=deep+vein+thrombosis&selectedTitle=3
%7E150
http://www.uptodate.com/contents/approach-to-the-diagnosis-and-therapy-oflower-extremity-deep-veinthrombosis?source=search_result&search=deep+vein+thrombosis&selectedTitle=
1%7E150
http://www.uptodate.com/contents/deep-vein-thrombosis-and-pulmonaryembolism-in-pregnancytreatment?source=search_result&search=deep+vein+thrombosis&selectedTitle=7
%7E150
http://www.uptodate.com/contents/fibrinolytic-thrombolytic-therapy-in-acutepulmonary-embolism-and-lower-extremity-deep-veinthrombosis?source=search_result&search=deep+vein+thrombosis&selectedTitle=
4%7E150